Barbara Cannin, an 18-year-old female, came to see her physician, Dr.
Cordoba. She had something in her eye, and it was irritating her. Nothing she
did could get it out. Dr. Cordoba took a problem-focused history and
examined the area. He then applied a topical anesthetic and removed the
foreign body from the superficial conjunctiva of her eye. Code the removal of
the foreign body only.
Michael Munsey, an 84-year-old male, was seen by his physician at an
ambulatory surgical center for the insertion of a temporary transvenous
single-chamber cardiac electrode. The patient tolerated the procedure well.
Marlene Carrington, a healthy 42-year-old female, was taken to the operating
room (OR) for an anterior cervical discectomy with decompression of a single
interspace of the spinal cord and nerve roots and including osteophytectomy.
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual - CPT
Alphabetic Index
What is the key term - Discectomy
What is the anatomic site - Cervical
What is the approach - Anterior
What else do we know about it - Decompression of a single interspace of the
spinal cord and nerve roots was performed
What else do we know about it - Includes osteophytectomy
Begin to code the encounter
Did you verify the code in the numerical listing - Yes
Is there a symbol for this code - No
If so what does the symbol mean - Does not apply
Is there an additional notation - Yes
If so does the notation apply -Does not apply
Do you need to add a modifier - No
If so what is the modifier - Does not apply
Did you check the guidelines - Yes
Did you code to the highest level of specificity - Yes
What is the correct procedure code - 63075
Overall Feedback:
63075: Index>discectomy>cervical
, The hashtag symbol identifies
an out-of-numeric-sequence code.
The main body of the CPT book has _____ sections, presented in numeric
order (for the most part) by code number.
6
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: MURRAY, CARMEL
ACCOUNT/EHR #: MURRCA001
DATE:
Attending Physician: Oscar R. Prader, MD
S: This new patient is a 32-year-old female who comes in with a complaint of
severe neck pain and difficulty turning her head. She states she was in a car
accident 2 days ago; her car was struck from behind when she was driving
home from work.
O: PE reveals tightness upon palpation of ligaments in neck and shoulders,
most pronounced C3 to C5. X-rays are taken of the cervical vertebrae, three
views (AP, Lat, and PA). Radiologic review denies any fracture.
A: Anterior longitudinal cervical sprain
P:
1. Prescribed cervical collar to be worn during all waking
2. Rx Vicodin (hydrocodone) 500 mg po prn
3. 1,000 mg aspirin
4. Pt to return in 2 weeks for follow-up
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual – Alphabetic Index
Cordoba. She had something in her eye, and it was irritating her. Nothing she
did could get it out. Dr. Cordoba took a problem-focused history and
examined the area. He then applied a topical anesthetic and removed the
foreign body from the superficial conjunctiva of her eye. Code the removal of
the foreign body only.
Michael Munsey, an 84-year-old male, was seen by his physician at an
ambulatory surgical center for the insertion of a temporary transvenous
single-chamber cardiac electrode. The patient tolerated the procedure well.
Marlene Carrington, a healthy 42-year-old female, was taken to the operating
room (OR) for an anterior cervical discectomy with decompression of a single
interspace of the spinal cord and nerve roots and including osteophytectomy.
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual - CPT
Alphabetic Index
What is the key term - Discectomy
What is the anatomic site - Cervical
What is the approach - Anterior
What else do we know about it - Decompression of a single interspace of the
spinal cord and nerve roots was performed
What else do we know about it - Includes osteophytectomy
Begin to code the encounter
Did you verify the code in the numerical listing - Yes
Is there a symbol for this code - No
If so what does the symbol mean - Does not apply
Is there an additional notation - Yes
If so does the notation apply -Does not apply
Do you need to add a modifier - No
If so what is the modifier - Does not apply
Did you check the guidelines - Yes
Did you code to the highest level of specificity - Yes
What is the correct procedure code - 63075
Overall Feedback:
63075: Index>discectomy>cervical
, The hashtag symbol identifies
an out-of-numeric-sequence code.
The main body of the CPT book has _____ sections, presented in numeric
order (for the most part) by code number.
6
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: MURRAY, CARMEL
ACCOUNT/EHR #: MURRCA001
DATE:
Attending Physician: Oscar R. Prader, MD
S: This new patient is a 32-year-old female who comes in with a complaint of
severe neck pain and difficulty turning her head. She states she was in a car
accident 2 days ago; her car was struck from behind when she was driving
home from work.
O: PE reveals tightness upon palpation of ligaments in neck and shoulders,
most pronounced C3 to C5. X-rays are taken of the cervical vertebrae, three
views (AP, Lat, and PA). Radiologic review denies any fracture.
A: Anterior longitudinal cervical sprain
P:
1. Prescribed cervical collar to be worn during all waking
2. Rx Vicodin (hydrocodone) 500 mg po prn
3. 1,000 mg aspirin
4. Pt to return in 2 weeks for follow-up
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual – Alphabetic Index
